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Eosinophilic Esophagitis . Case Presentation 35 year old man presented with intermittent upper esophageal dysphagia, mostly with solids for > 5 years. It had become progressively worse and he had problems swallowing “any solid food”. No weight loss. No heartburn symptoms.

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Presentation Transcript
slide2
Case Presentation

35 year old man presented with intermittent upper esophageal dysphagia, mostly with solids for > 5 years.

It had become progressively worse and he had problems swallowing “any solid food”.

No weight loss. No heartburn symptoms.

No prior treatment, no current meds

slide3
EGD

Although no stricture was seen in the esophagus or the GE junction, moderate pressure was needed to advance to this point.

Multiple rings were seen intermittently throughout the esophagus.

The endoscopy could not be advanced beyond the GE junction

due to the floppy, tortuous esophagus.

slide4
As the scope was withdrawn a 3cm superficial mucosal tear was seen in the mid esophagus.

Michael B. Harper, M.D.

slide6
There was no blood loss.

Although the mucosa did not appear inflamed, it was friable and thin.

Michael B. Harper, M.D.

slide8
Multiple cold forceps biopsies were taken from the GE junction and middle third of the esophagus

avoiding the site of the mucosal injury

impression
Impression
  • Friable mucosa, with superficial linear tear.
  • Eosinophilic esophigitis, Strongly suspected

Michael B. Harper, M.D.

slide10
Plan
  • Soft diet for 24 hours after EGD (due to mucosal injury)
  • Start esomeprazole 40gm/d

Michael B. Harper, M.D.

pathology report
Pathology report
  • Both biopsies display esophageal squamous mucosa with acute basal cell hyperplasia
  • and increased eosinophilic inflammation with areas in excess of 30 eosinophils per high power field consistent with eosinophilic esophagitis.
  • A PAS-D stain performed on the mid esophageal biopsy showed no evidence of fungal microorganisms.

Michael B. Harper, M.D.

slide12

marked basal zone hyperplasia

Michael B. Harper, M.D.

slide13

large numbers of eosinophils

greater than 40 per high power field

Michael B. Harper, M.D.

plan following path report
Plan following path report
  • Started fluticasone 220ucg bid, do not inhale, and rinse mouth with small amount of water
  • Changed to lansoprazole orally disintegrating tablet
    • dysphagia with capsule
  • Consult allergist for food allergy testing and elimination diet

Michael B. Harper, M.D.

plan following path report1
Plan following path report
  • Plan repeat EGD
    • After 6 weeks of treatment

with pediatric endoscope

    • To confirm stomach and duodenum not involved
  • TNE if further esophageal exams needed

Michael B. Harper, M.D.

slide16
The mucosa may appear normal

Multiple rings are a typical finding

Corrugation

"trachea-like"

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.

slide17
linear furrowing

ulceration and strictures

multiple whitish papules or granular exudates

Other finding seen with

eosinophilic esophagitis

Michael B. Harper, M.D.

slide18
Perforations are common

do not force the endoscope

avoid dilatation

or wait until after treatment

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.

slide19
Diagnosis is based on clinical presentation and finding eosinophils on bx

Number per HPF not agreed upon

>15-25 is typically used

Eosinophils can be caused by GERD

Best to biopsy after treatment with PPI for at least 4 weeks

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.